ASBHDS

Question 1

Define the term ‘adverse event’.

Answer 1

Injury caused by MEDICAL MANAGEMENT (rather than underlying disease) and that PROLONGS HOSPITALISATION and/or produces a DISABILITY.

Question 2

Define and give examples of the 2 types of adverse events.

Answer 2

1. PREVENTABLE adverse event
   
   • adverse event that could be prevented given the current state of medical knowledge.
   • e.g. wrong side operation, retained surgical instrument, some HAIs, wrong dose/medication
2. UNAVOIDABLE adverse event
   
   • e.g. drug reaction that occurs when P prescribed drug for 1st time

Question 3

Suggests ways in which the health care environment could be made safer.

Answer 3

1. avoid reliance on memory (e.g. written protocols available on ward)
2. make things visible (e.g. colour coding different drugs)
3. review and simplify processes
4. standardise common processes and procedures
5. routinely use checklists (e.g. for handovers)
6. decrease reliance on vigilance

Question 4

Which 2 types of factor are required in Reason’s ‘Swiss Cheese’ framework of error? Give examples of each.

Answer 4

1. ACTIVE FAILURES
   - ‘visible’ acts that directly lead to P being harmed, by clinicians closely involved in care (individual error)
   - e.g. administration of wrong dose to baby causing seizures
2. LATENT CONDITIONS
   - any aspect of context in which care is provided that PREDISPOSES to occurence of active failures
   - e.g. poor training, too few staff, poor design of syringe

Question 5

Describe the 4 subcategories of human error/active failures.

Answer 5

1. SLIPS - error of commission/failure of attention (e.g. give 100mg dose instead of 10mg)
2. LAPS - error of omission/failure of memory (e.g. forgot to give dose)
3. MISTAKES - rule based (poor decision making) or knowledge based (lack of education (e.g. thought 100mg dose would be better than 10mg)
4. VIOLATIONS - malicious (e.g. intentionally give OD)

Question 6

What is the difference between 1st order and 2nd order problem solving?

Answer 6

1st order problem solving

• do WHAT IT TAKES TO CONTINUE P CARE, no more no less (meets immediate needs and minimises time away from patient care)
• ask for HELP FROM PEOPLE WHO ARE SOCIALLY CLOSE rather than those best equipped to correct problem (preserves reputation, minimises difficult encounters)

2nd order problem solving
- successfully act to PREVENT PROBLEM RECURRING (+ve effects for workers, customer and organisation, and decreased risk of errors recurring/causing harm)

Question 7

Suggest reasons why 1st order problem solving might be used instead of 2nd order.

Answer 7

• too busy
• afraid of innovative approach (wait for NICE guidelines)
• resistance to change
• lack of communication

Question 8

What is Systems Analysis? Name 3 techniques that might be used for this.

Answer 8

Structured approach to the RETROSPECTIVE investigation of adverse events in healthcare, focussing on identification of the LATENT UNDERLYING FACTORS causing the problem.

Aims to answer:

1. What happened?
2. Why did it happen?
3. What can be done to prevent it happening again?

Techniques: fishbone diagram, 5 whys, timeline

Question 9

Describe the PDSA cycle.

Answer 9

1. PLAN - what are we going to do?
2. DO - when and how do/did we do it?
3. STUDY - what were the results?
4. ACT - what changes are we going to make based on our findings?

Question 10

Suggest reasons why speaking up about safety concenrs may be difficult.

Answer 10

1. hierarchy/authority gradients
2. no certainty it will give rise to improvements
3. can provoke informal hostility/reduce quality of working relationships
4. uncertainty something is really a problem

Question 11

What are the 3 Cs of patient and public involvement?

Answer 11

1. CONSULTATION = asking members of the public for their views about research (e.g. identifying topics, implications of findings), and using these to inform decision-making.
2. COLLABORATION = ongoing partnership between researcher and members of public, e.g. in developing research grant application, study advisory group or result dissemination.
3. CO-PRODUCTION = public members and ‘professionals’ are involved on an equal footing through every stage of design and delivery of research.

Question 12

Name 2 benefits and 2 challenges of consultation in PPI.

Answer 12

Benefits:

1. useful when exploring SENSITIVE and DIFFICULT issues
2. get a WIDE RANGE OF VIEWS

Challenges:

1. might not get broad views hoped for
2. people might have previous bad experiences where their views were not listened to

Question 13

Name 2 benefits and 2 challenges of collaboration in PPI.

Answer 13

Benefits:

1. skills and perspectives of public and researchers can complement one another
2. can help with recruitment and informed consent

Challenges:

1. time-consuming and additional costs
2. researchers need to be flexible and willing to share control of research